Distant pedicle flaps for soft tissue coverage of severely burned hands: an old idea revisited.

Burns to the hand that are complicated by exposure of bone, joint or tendon cannot be closed with conventional skin grafts and require flap procedures to prevent further damage. Local or regional flaps may be unavailable if electrical or blast trauma produces a large zone of injury, or when forearm burn injury extends beyond fascia. Free tissue transfer may not be tolerated by critically ill burn patients. In these circumstances, distant pedicle flaps are one option for safe and effective soft tissue coverage. Over a 5-year period, we have performed six distal pedicle flaps for coverage of exposed hand structures when local or free flaps were contraindicated or unavailable. The patients required an average of 4.5 surgical procedures to complete hand reconstruction and soft tissue coverage. Soft tissue coverage was completely successful in five patients and partially successful in one patient. Single stage local or free flaps remain the treatment of choice when burned hands cannot be covered with skin grafts. When these flap options are not available, distant pedicle flaps provide a safe alternative.

Burns caused by medical therapy.

A burn injury may occur as an unexpected consequence of medical treatment. We examined the burn prevention implications of injuries received in a medical treatment facility or as a direct result of medical care. The records of 4510 consecutive admissions to 1 burn center between January 1978 and July 1997 were retrospectively reviewed. A cohort of 54 patients burned as a result of medical therapy was identified and stratified by location (home vs medical facility) and by mechanism of injury. Twenty-two patients were burned in a medical treatment facility, including 12 patients who were burned as a result of careless or unsupervised use of tobacco products. Thirty-two patients were burned as a result of home medical therapy, including 9 patients who had scald injuries from vaporizers, 8 patients who were burned by simultaneous use of cigarettes and home nasal oxygen therapy, and 11 patients who were burned by therapeutic application of heat. In contrast to previous studies, no patient was burned by the use of medical laser devices. To further decrease burn risk from medical therapy we advocate the prohibition of cigarette smoking in any medical facility. Continued tobacco use may represent a contraindication to home oxygen therapy. Given the lack of proof of efficacy combined with the potential for burn injury, the use of vaporizers to treat upper respiratory symptoms should be discouraged. Patients with diminished sensation or altered mental status are at increased risk of burn injury from bathing or topical heat application and merit closer monitoring during these activities.

The fire-safe cigarette: a burn prevention tool.

Cigarettes are the most common ignition source for fatal house fires, which cause approximately 29% of the fire deaths in the United States. A common scenario is the delayed ignition of a sofa, chair, or mattress by a lit cigarette that is forgotten or dropped by a smoker whose alertness is impaired by alcohol or medication. Cigarettes are designed to continue burning when left unattended. If they are dropped on mattresses, upholstered furniture, or other combustible material while still burning, their propensity to start fires varies depending on the cigarette design and content. The term "fire-safe" has evolved to describe cigarettes designed to have a reduced propensity for igniting mattresses and upholstered furniture. Legislative interest in the development of fire-safe smoking materials has existed for more than 50 years. Studies that showed the technical and economic feasibility of commercial production of fire-safe cigarettes were completed more than 10 years ago. Despite this, commercial production of fire-safe smoking materials has not been undertaken. The current impasse relates to the lack of consensus on a uniform test method on which to base a standard for fire-safe cigarettes. Although the fire-safe cigarette is a potentially important burn prevention tool, commercial production of such cigarettes will not occur until a standard against which fire-starting performance can be measured has been mandated by law at the state or federal level. The burn care community can play a leadership role in such legislative efforts.

Acute respiratory failure that complicates the resuscitation of pediatric patients with scald injuries.

Respiratory failure that requires endotracheal intubation is an uncommon but potentially fatal complication of scald burns in children. Because scalds are rarely associated with a direct pulmonary injury, the pathophysiology of respiratory failure is unclear. A possible mechanism may be upper airway edema, diminished pulmonary compliance secondary to fluid resuscitation, or both. To identify an at-risk population for intubation after a scald injury, the hospital courses of 174 consecutive patients under the age of 14 years who were admitted after a scald injury to a single burn center during a 6-year period were examined. Seven of these patients (4%) required endotracheal intubation. No patient older than 2.8 years or who had a scald injury that covered less than 19% of the total body surface area required intubation. Patients who required intubation were younger (mean age, 1.4 vs. 2.8 years, P<.001), had a larger mean burn size (29.9% vs. 12.3% total body surface area, P<.001), and required more fluid resuscitation (7.66 vs. 4.07 cc/kg per percentage of total body surface area burned, P<.001) than patients who did not require intubation. Examination of the adequacy of resuscitation revealed that the intubated patients had an average hourly urine output of 0.84 cc/kg during the first 24 hours, suggesting that resuscitation was not excessive. Multivariate analysis demonstrated that both larger burn size (P = .041) and younger age (P = .049) were independent predictors of the need for intubation. Young patients with large body surface area burns that required large volumes of resuscitation comprise an at-risk group for respiratory failure after a scald injury. Increased vigilance is merited during the resuscitation of these patients.

Dermatologists and the burn center.

Severe cutaneous disease and injury often is best treated in the specialized treatment environment of a burn center. Skilled burn treatment personnel combine critical care expertise with extensive clinical experience in the management of severe cutaneous injury and disease. In addition to thermal injury, the burn center is the ideal environment for patients with progressive toxic epidermal necrolysis, pemphigoid lesions, and invasive cutaneous infection. Recent research indicates that the burn wound is a dynamic structure whose ultimate extent is modifiable by manipulations of the local anatomic and molecular environment. The many unanswered questions on the pathogenesis and treatment of both the "medical" and "surgical" cutaneous processes require close collaboration between the dermatologist and the burn team.

Elder abuse: a call to action.

An estimated 2 million people a year are victims of elder abuse, which ranges from neglect and mistreatment to physical abuse. By the year 2020, a full 22% of the population will be aged 65 or older. This demographic explosion demands that we identify and protect those at risk. To investigate the incidence of elder abuse or neglect (EAN) and to determine clinician awareness of associated risk factors, we conducted a 1-year retrospective review of thermally injured patients aged 60 or older. Data included age, total body surface area burned, mechanism of injury, length of hospital stay, mortality, abuse or neglect risk factors, and referral to the appropriate social agency. We found that our elderly patients (n = 28) were poorly screened for EAN. While 64% to 96% of patients were screened for cognitive impairment, overall health, and financial resources, none were screened for risk factors of emotional isolation. None of the patient's caregivers, including any spouses, roommates, or guardians, were screened for risk factors of substance abuse, familial violence, dependency needs, or external stresses. With the use of available data, we were able to place 11 patients on the following levels of abuse or neglect: 1) low risk for abuse; 2) self-neglect; 3) neglect; and 4) abuse. By this scale, 7 patients (64%) were victims of self-neglect, 3 patients (27%) were victims of neglect, and 1 patient (9%) was a victim of abuse. Adult Protective Services intervened in 2 cases. Recognizing that all cases of EAN should be preventable, we cannot accept the socioeconomic impact of this entity. The 11 patients identified as victims of neglect, self-neglect, or abuse accounted for 135 hospital days and 8 fatalities. Before we can address EAN, health care personnel must be made aware of the problem and routine screening for risk factors must be implemented. The true incidence of EAN is likely underestimated because health care providers have difficulty recognizing its features. A standard assessment tool to screen for neglect or abuse should be used for each older adult admission.

Preventable burns associated with the misuse of gasoline.

Gasoline is intended for use as a motor fuel, but the universal availability of gasoline in the home encourages misuse as a solvent, insecticide, accelerant or cleaning solution. The careless or inappropriate use of gasoline may result in burn injury. We examined the circumstance of gasoline-related injury in a population admitted to one burn centre to determine the potential for burn prevention efforts. A retrospective review of all burn admissions to one centre for the years 1978 to 1996 demonstrated hat 1011 of 4339 acute admissions (23.3%) were gasoline-related. This group had an average total burn size of 29.8% total body surface (TBSA) and an average full thickness injury of 14.4% TBSA. There were 144 fatalities resulting from gasoline-associated burn injury. Where such determination could be made, the use of gasoline was judged to be inappropriate or unsafe in 687 of 788 cases (87.1%). Ninety of 144 fatalities (62.5%) were associated with inappropriate or unsafe use of gasoline. The careless or inappropriate use of gasoline poses significant risk of burn injury. The indoor use of gasoline, as well as use of gasoline for purposes other than as a motor fuel, should be strongly discouraged.

Fatal and near-fatal complications of liposuction.

Cosmetic liposuction is considered to be safe and effective in properly selected patients and is widely done as an outpatient or office procedure. When major complications occur, office-based practitioners may refer patients to a hospital emergency department, where medical personnel unfamiliar with this procedure may underestimate the risk of serious infection or other major complications. We present two cases of massive necrotizing fasciitis treated in a burn center after liposuction surgery. One patient died, and the second required lengthy hospitalization, extensive debridement, and split-thickness skin grafting of 22% of the total body surface area. Pain out of proportion to clinical findings is a hallmark of necrotizing fasciitis and should prompt consideration of this entity even in the absence of cutaneous signs of infection. Definitive diagnosis is made by biopsy and rapid section histologic analysis. Liposuction may result in major complications or death. Emergency department physicians or general surgeons may be called upon to manage such complications and should be aware of these risks.

Body habitus as a predictor of burn risk in children: do fat boys still get burned?

Previous research at this institute has demonstrated that heavy-for-age boys are more burn prone than their normal sized counterparts. As this study is now 26 years old, we reexamined the anthropomorphic indices of 372 children admitted to one burn center between January 1991 and July 1997 to determine if this trend was still evident. Male children were over-represented in the < or =5th and >95th percentiles for both height (p < 0.001, p < 0.05) and weight (p < 0.01, p < 0.001). Female children were over-represented in the < or =5th and > 95th percentiles for height (p < 0.01, p < 0.05). Twenty-eight percent of boys at or below the 5th percentile for weight were burned as a result of known or suspected intentional injury, compared to 5.9% of the entire pediatric burn population. (p < 0.0004). 'Fat boys' continue to be over-represented in the pediatric burn population. Additionally, in the more recent time period, boys at or below the 5th percentile for height or weight and girls= < 5th percentile or >95th percentile for height are also over-represented. The increased frequency of burn injury in small-for-age children may reflect an increased risk of burn injury secondary to neglect or nonaccidental trauma.

Prospective outcome analysis of a protocol for the surgical and rehabilitative management of burns to the hands.

Treatment protocols for the management of burned hands are essential for integrating team efforts and achieving optimal functional results. Standard protocols are especially useful during mass casualty incidents, when the admission of multiple patients with large burns and/or associated injuries may reduce the priority usually accorded the hands. We prospectively evaluated a surgical and rehabilitative treatment protocol for burned hands during a mass casualty incident, after which 43 burn patients with 82 burned hands were admitted to one burn center. Soft-tissue management was individualized to achieve, if possible, wound closure within 14 days, and included the use of topical antimicrobials, cutaneous debridement and/or tangential excision, biologic dressings, and split-thickness autografts. Range of motion therapy was based on daily measurement of active motion of the metacarpophalangealjoints. Static splinting alternating with continuous passive motion every 4 hours was utilized for sedated patients. Continuous passive motion alternating with active ranging and night splinting was utilized for metacarpophalangeal flexion <70 degrees. Active ranging and progressive resistance was utilized for metacarpophalangeal flexion > or =70 degrees. Sixty-four hands required excision and grafting, with 89 percent having at least one autografting procedure completed by postburn day 16. Total active motion of the hands treated averaged 220.6 degrees on discharge and 229.9 degrees at 3 months after injury. Mean hand grip strength was 60.8 pounds at discharge and 66.0 pounds at 3 months after injury. Adherence to a standard hand burn protocol resulted in timely wound coverage and recovery of hand function for a large group of patients treated at a single burn facility after a mass casualty incident.

Burn management. Nonthermal injuries.

The return to optimal function for patients who sustain chemical and electrical injuries depends on immediate emergency treatment and burn center referral for definitive care. Patients with exfoliating diseases also require care provided by a burn center. Critical care nurses, along with other members of a multidisciplinary health care team, must be dedicated to the principles of infection control, pain management, and psychosocial care to ensure positive outcomes and the return of these citizens to society.

Pressure-controlled ventilation for the long-range aeromedical transport of patients with burns.

Pressure-controlled ventilation is used to treat smoke inhalation injury to achieve adequate oxygenation and ventilation at lower peak inspiratory pressures. A portable pressure-controlled time-cycled transport ventilator permits this modality to be used in the field. We have examined the safety and efficacy of this ventilator for aeromedical transfer of thermally injured patients. Burn flight teams transported 146 intubated patients with thermal injury to the U.S. Army Burn Center with this system. The average extent of burn injury was 40.45% total body surface area with an average full-thickness injury of 25.29% total body surface area. The transport ventilator was used for 57 rotary wing and 89 fixed wing missions. The study group was transported a total of 86,889 miles without in-flight morbidity, mortality, or failure of ventilation. Arterial blood gas analysis at conclusion of flight demonstrated an arterial pH > or = 7.35 in 85% of the patients, an arterial partial pressure of carbon dioxide < or = 45 torr in 97%, and an arterial partial pressure of oxygen > or = 70 torr in 99%. Pressure-controlled ventilation performed by an experienced transport team with this ventilator is safe and effective for the long-range aeromedical transfer of intubated patients with burns.

Computer-assisted evaluation of hand and arm function after thermal injury.

Comprehensive care of the burned upper extremity requires accurate and complete evaluation of function, including two-point discrimination, active and passive range of motion, and grip strength. These evaluations, when performed serially during a course of therapy, are time-consuming and manpower-intensive. We tested the utility and accuracy of a commercially available computer-assisted impairment evaluation system when used to automate and standardize measurement of upper-extremity function. The function of 80 upper extremities was evaluated with both the conventional and the computer-assisted methods. The time required to perform a complete examination with each method was recorded, and measurements of grip strength and total active motion made with both methods were compared. Complete upper-extremity evaluation required an average of 20.3 minutes with the computer-assisted method, compared to 62.9 minutes with conventional means. Measurements of extremity function with computer-assisted and conventional methods had correlation coefficients of 0.984 for grip strength and 0.996 for total active motion. The computer-assisted impairment evaluation system was found to be a useful and accurate adjunct in the acute and rehabilitative management of burned upper extremities.

Fire fatality study: demographics of fire victims.

Injury or death caused by fire is frequent and largely preventable. This study was undertaken to define the populations, locations, times and behaviours associated with fatal fires. Seven hundred and twenty-seven fatalities occurring within the State of New Jersey, between the years 1985 and 1991, were examined retrospectively. Most deaths were attributed to a combination of smoke inhalation and burn injury. Five hundred and seventy-four fatalities occurred in residential fires. Smoking materials were the most common source of ignition for residential fires. More than half of the fatal residential fires started between the hours of 11 p.m. and 7 a.m. Children and the elderly represented a disproportionate percentage of fire victims. Victims under the age of 11 years or over the age of 70 years constituted 22.1 per cent of the state population but 39.5 per cent of all fire fatalities. Fire-prevention efforts should target home fire safety, and should concentrate on children and the elderly. The development of fire-safe smoking materials should be encouraged.

Aeromonas bacteraemia in burn patients.

Human aeromonas infection is uncommon and is usually associated with immunosuppression, chronic disease or trauma in an aquatic setting. Burn injury may induce a state of immunosuppression, making the thermally injured patient a suitable host for aeromonas infection. We reviewed the experience of one burn centre with this pathogen. Retrospective examination of blood culture results from 8151 patients admitted between 1959 and 1994 disclosed eight patients with clinically relevant Aeromonas hydrophilia bacteraemia. Five were burned outside the USA. Aquatic exposure was known or suspected in only three cases. Five of the eight patients died. Aeromonas infection in burn patients is rare but may occur in the absence of aquatic exposure.

Substance abuse in victims of fire.

Ethanol or drug use may increase the risk of fire-related injury or death. This study was performed to quantify the role of substance abuse in fatal fires occurring in New Jersey over a 7-year period. Records of all the fatalities of fire reported to the State Medical Examiners Office between 1985 and 1991 were retrospectively examined. Blood assay results for ethanol were positive in 215 of the 727 (29.5%) fatalities of fire tested. For this group, the mean blood-ethanol level was 193.9 mg/dl. Blood or urine assay results for substances of abuse were positive in 78 of the 534 (14.6%) fatalities tested. The most commonly detected illicit substances were cocaine, benzodiazepines, barbiturates, and cannabinoids. The test results were positive for both ethanol and drug use in 36 victims. Forty percent of all the fatalities of fire were aged younger than 11 or older than 70. In contradistinction, 75% of drug-positive fatalities of fire and 58% of ethanol-positive fatalities of fire were between the ages of 21 and 50, suggesting that inebriation may impair the ability to escape from fire. Substance abusers in middle life are a previously unrecognized group at higher risk of injury or death in a fire.

Thermal trauma resulting from motor vehicle operation or maintenance.

Burn injury may result from the operation or maintenance of motor vehicles. We reviewed the experience of one burn center with injuries related to motor vehicle use over the 6 year period 1987-1992. One hundred and fifty patients with motor vehicle related burns were identified comprising 11.3% of all admissions for this period. The mean extent of burn injury was 22.8% total body surface area with a mean full thickness (third degree) burn size of 11.7%. The average hospital length of stay was 42.41 days. The most common mechanisms of injury were collisions resulting in fire (n = 48), carburetor priming (n = 37) and scalding from radiator fluid contact (n = 27). Burns resulting from vehicle operation or maintenance are costly and potentially preventable.

Cyanide poisoning in victims of fire: analysis of 364 cases and review of the literature.

Cyanide is produced by the combustion of natural and synthetic materials. It is assumed that cyanide poisoning is a major component of smoke inhalation injury; however, scientific verification of this assumption is lacking. In this study we examined blood carboxyhemoglobin and cyanide levels in fire fatalities. Carboxyhemoglobin levels of 433 fatalities averaged 44.9% and exceeded fatal (> or = 50%) levels in 195 cases. Cyanide levels of 364 fatalities averaged 1.0 mg/L and exceeded fatal levels (> 3 mg/L) in 31 cases. For victims with cyanide levels above 3 mg/L the mean carboxyhemoglobin level was 62.5%. Cyanide poisoning is infrequent in fire fatalities, and when present it is associated with significant carboxyhemoglobinemia. Cyanide can be both produced and degraded in blood and tissue, making interpretation of blood levels difficult. In survivors of fire, detoxification of cyanide can occur without specific antidotes with the use of aggressive supportive care. Specific assay and treatment for cyanide poisoning is rarely necessary in the treatment of victims of smoke and fire.

Arrest and conviction of injured intoxicated drivers in eastern Pennsylvania.

The legal hazards of driving under the influence (DUI) are frequently not appreciated by alcohol users. Physicians who treat such patients following collisions are often unaware of the judicial disposition following hospital discharge. We examined the courthouse records of 511 intoxicated drivers involved in collisions and admitted to one Level I Trauma Center to determine if DUI arrests and convictions were obtained. The proportion arrested for DUI ranged from 6%-54% (mean 41%) depending on county of crash site and distance from the trauma center. Of those arrested, the proportion of DUI convictions averaged 98% for all jurisdictions. Two hundred and nineteen intoxicated drivers were transported from the crash scene by helicopter. Increased transport distance was associated with a lower arrest proportion (p = 0.01). Most injured intoxicated drivers in this study were not arrested for DUI. Of those identified and arrested, conviction was a virtual certainty. Helicopter transport may provide additional protection from prosecution.

Preliminary experience with cultured epidermal autograft in a community hospital burn unit.

Initial experience with cultured epidermal autograft (CEA) in a community hospital burn unit is described. Five applications of CEA to three patients (mean burn size, 59% total body surface area) were made. Final graft "take" of CEA ranged from 10% to 80%. Healed CEA is cosmetically superior to meshed autograft and appears to form less hypertrophic scar tissue. CEA is more sensitive to infection than meshed autograft. A review of the literature concerning topical antibiotic use with CEA is included. This experience with CEA demonstrates that large burns can be successfully managed with this modality in a community hospital burn unit setting.